Description

Summary

This is a pilot study of pembrolizumab-based therapy in previously treated extrapulmonary poorly differentiated neuroendocrine carcinoma

Official Title

A Pilot Study of Pembrolizumab-based Therapy in Previously Treated High Grade Neuroendocrine Carcinomas

Details

There are two parts of the study. In Part A, subjects are treated with pembrolizumab alone, and in Part B with pembrolizumab plus chemotherapy (physician's choice, paclitaxel or irinotecan). Adaptive Simon's two-stage design is used. The overall plan hinges on the activity of single agent pembrolizumab in the first stage of Part A. If there is sufficient activity in the first stage of Part A, the study will expand to the second stage of Part A and forgo Part B. If there is insufficient activity in the first stage of Part A, the study will proceed to the first stage of Part B (pembrolizumab plus chemotherapy).

Eligibility

You can join if…

Be willing and able to provide written informed consent for the trial.

Be at least 18 years of age on day of signing informed consent.

Have a histologically proven locally advanced or metastatic high grade neuroendocrine carcinoma (NEC)

Includes small cell and large cell neuroendocrine carcinoma of unknown primary or any extrapulmonary site

Includes well differentiated G3 neuroendocrine neoplasms if KI67>30%

Includes neuroendocrine prostate cancer (de novo or treatment-emergent) of prostate if small cell or large cell histology

Mixed tumors, e.g. mixed adenoneuroendocrine carcinoma (MANEC) or mixed squamous or acinar cell NEC are allowed if the high grade (small or large cell) NEC component comprises >50% of the original sample or subsequent biopsy

Have progressed during or after completion of first line systemic therapy

No limit to the number of prior chemotherapy regimens

Have at least one measurable disease based on RECIST 1.1

Patients must agree to have a biopsy of metastatic tissue at baseline, and there must be a lesion that can be biopsied with acceptable clinical risk (as judged by the investigator).

Patients with unsuccessful baseline biopsies may undergo an additional biopsy attempt (at the same or a different site, determined by the investigator).

For patients with an intact primary and no metastatic site that can be safely biopsied, biopsy of the primary is acceptable, but must be approved by the principal investigator.

Baseline tumor biopsy may be omitted if the tumor is inaccessible and/or a biopsy is not thought to post exceptionally high procedural risk due to location or other factors

Have a performance status of 0 or 1 on the Eastern Cooperative Oncology Group (ECOG)Performance Scale.

Have a life expectancy of greater than 3 months.

Demonstrate adequate organ function, all screening labs should be performed within 10 days of treatment initiation.

. Female subject of childbearing potential should have a negative urine or serum pregnancy within 72 hours prior to receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required.

. Female subjects of childbearing potential should be willing to use 2 methods of birth control or be surgically sterile, or abstain from heterosexual activity for the course of the study through 120 days after the last dose of study medication (Reference Section 5.7.2). Subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year.

. Male subjects should agree to use an adequate method of contraception starting with the first dose of study therapy through 120 days after the last dose of study therapy.

Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject.

You CAN'T join if...

Has Merkel cell carcinoma, small cell lung carcinoma, or large cell NEC of lung

Intermediate grade neuroendocrine tumors are excluded

Metastatic high-grade prostate carcinoma with evidence of focal neuroendocrine differentiation on prostate biopsy (e.g., positive chromogranin staining by immunohistochemistry) without small cell or large cell NEC morphology are excluded, as are neuroendocrine prostate cancers with phenotype intermediate between adenocarcinoma and small cell

Is currently participating and receiving study therapy or has participated in a study of an investigational agent and received study therapy or used an investigational device within 4 weeks of the first dose of treatment.

Has a diagnosis of immunodeficiency

Is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment.

History of or high suspicion of Gilbert's disease (safety run-in, Part B only)

Hypersensitivity to pembrolizumab or any of its excipients.

Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to agents administered more than 4 weeks earlier.

Documented progression on and/or intolerance/hypersensitivity to both paclitaxel and irinotecan (Part B only)

. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously administered agent.

Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study.

Note: If subject received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy.

Concurrent somatostatin analog therapy is allowed (for control of hormone excess)provided patient has been on stable dose for at least two months and tumor progression has been documented

. Has a known additional malignancy that is progressing or requires active treatment.Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer.

. Has known active central nervous system (CNS) metastases and/or carcinomatous meningitis. Subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to the first dose of trial treatment and any neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain metastases, and are not using steroids for at least 7 days prior to trial treatment. This exception does not include carcinomatous meningitis which is excluded regardless of clinical stability.

. Has active autoimmune disease that has required systemic treatment in the past 2 years(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs).

Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment.

. Has a history of (non-infectious) pneumonitis that required steroids or current pneumonitis

. Evidence for interstitial lung disease

. Has an active infection requiring systemic therapy.

. Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate, in the opinion of the treating investigator.

. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial.

. Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the pre-screening or screening visit through 120 days after the last dose of trial treatment.

. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.

. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).

. Has received a live vaccine within 30 days of planned start of study therapy.

Note: Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated vaccines, and are not allowed.